Deficiencies (last 5 years)
Deficiencies (over 5 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
4% better than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
100% occupied
Based on a April 2025 inspection.
Occupancy rate over time
Notice
Deficiencies: 0
Date: Nov 20, 2025
Visit Reason
This document serves as a Notice of Privacy Practices informing individuals about how their medical information may be used and disclosed by NJDHSS and their rights related to this information.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and NJDHSS's legal duties and contact information for privacy concerns.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director | NJDHSS Privacy Officer listed as contact for privacy practices |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 19, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a medication error involving Resident #2, where the wrong medication was administered by a nurse.
Complaint Details
The complaint investigation found that the medication nurse administered insulin to the wrong resident due to distraction and failure to follow identification protocols. The incident was reported immediately, and the resident's physician ordered blood sugar monitoring. The Director of Nursing confirmed the policy requirements and stated no negative consequences occurred.
Findings
The facility failed to ensure Resident #2 was free from a medication error when the nurse administered insulin intended for another resident. The nurse did not follow facility policy for medication administration, including patient identification and the 5 Rights of Medication Administration. No negative consequences were reported for the resident.
Deficiencies (1)
Failure to ensure residents are free from significant medication errors, specifically administering the wrong medication to Resident #2.
Report Facts
Residents reviewed for medication administration: 3
Units of Novolog insulin administered: 4
Units of Lantus insulin administered: 16
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Nurse who administered the wrong medication to Resident #2 and reported the incident |
| Director of Nursing | Director of Nursing | Provided information on facility policy and confirmed no negative consequences for Resident #2 |
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 0
Date: Apr 14, 2025
Visit Reason
The inspection was conducted as a complaint survey based on complaint numbers NJ00179663, NJ00180032, and NJ00180090.
Complaint Details
Complaint numbers NJ00179663, NJ00180032, and NJ00180090 were investigated and found to be in compliance.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Report Facts
Sample Size: 5
Inspection Report
Annual Inspection
Census: 63
Deficiencies: 14
Date: Aug 15, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Complaint Details
Complaint #: NJ00163358, NJ00174088
Findings
Deficiencies were cited related to accuracy of assessments, comprehensive care plans, bowel/bladder incontinence care, food safety, infection prevention and control, and multiple life safety code violations including fire safety and maintenance.
Deficiencies (14)
Failed to accurately assess the status of a resident in the Minimum Data Set (MDS).
Failed to develop and implement comprehensive person-centered care plans for residents.
Failed to ensure appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.
Failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness.
Failed to perform hand hygiene as indicated and maintain a sanitary environment for infection control.
Failed to ensure sections of health care facilities classified as other occupancies were separated by two hour fire resistance rated construction.
Failed to maintain means of egress free of obstructions.
Failed to maintain commercial cooking equipment in accordance with NFPA standards.
Failed to ensure manual alarm boxes were continuously accessible.
Failed to make repairs and take corrective actions to fire sprinkler system deficiencies.
Failed to ensure penetrations through smoke/fire barriers were protected and smoke barrier doors fully closed.
Failed to ensure ventilation in resident bathrooms was functioning properly.
Failed to ensure emergency electrical generator was properly maintained and tested.
Failed to ensure fire/smoke door assemblies were inspected and tested annually.
Report Facts
Census: 63
Sample size: 17
Deficiency completion dates: Oct 15, 2024
Inspection Report
Routine
Deficiencies: 5
Date: Aug 15, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, infection control, care planning, catheter care, food safety, and overall facility sanitation.
Findings
The facility was found deficient in multiple areas including inaccurate resident assessments, incomplete and outdated care plans, inadequate catheter care and infection prevention practices, improper food handling and sanitation, and failure to perform hand hygiene during wound care. Deficiencies were generally of minimal harm with few residents affected.
Deficiencies (5)
Failure to accurately assess resident status in the Minimum Data Set (MDS), specifically failure to code the use of a wander/elopement alarm for Resident #16.
Failure to develop and implement complete, person-centered care plans including anticoagulant use, indwelling urinary catheter care, wander guard use, and skin impairment for multiple residents.
Failure to provide appropriate catheter care including lack of physician order to flush indwelling catheters and improper cleaning and storage of urinary catheter drainage bags for Residents #17 and #42.
Failure to handle potentially hazardous food properly including lack of labeling and dating of food items and inadequate use of beard guards by dietary staff.
Failure to perform hand hygiene as indicated during wound care and failure to maintain sanitary environment, including soiled bed linens and improper dressing protection for Resident #3.
Report Facts
Residents affected: 1
Residents affected: 4
Residents affected: 2
Residents affected: 9
Dates: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding care plan responsibilities and acknowledged deficiencies in care plans and infection control |
| Registered Nurse Unit Manager | RN Unit Manager (RN UM) | Interviewed regarding care plan initiation and wound care procedures |
| Infection Preventionist | Infection Preventionist (IP) | Interviewed regarding catheter care, hand hygiene, and infection control practices |
| Certified Nurse Aide #1 | CNA | Confirmed catheter cleaning practices |
| Licensed Practical Nurse #1 | LPN | Observed performing wound care without proper hand hygiene |
| Dietary Director #1 | Dietary Director (DD#1) | Observed with facial hair not properly covered and acknowledged beard guard use policy |
| Food Service Worker #1 | FSW | Observed with beard guard improperly worn |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Dec 8, 2022
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with the New Jersey Administrative Code, Chapter 8:39, Standards for Licensure of Long Term Care Facilities.
Findings
The facility was found to be in compliance with the applicable standards for licensure of long term care facilities, with no deficiencies cited.
Inspection Report
Routine
Deficiencies: 3
Date: Dec 8, 2022
Visit Reason
The inspection was conducted to assess compliance with food safety and COVID-19 vaccination requirements for contracted staff at the facility.
Findings
The facility was found deficient in properly handling and storing potentially hazardous foods, including failure to label and date food items, improper storage exposing food to air, and presence of debris on equipment. Additionally, the facility failed to consistently track and secure accurate documentation of COVID-19 vaccination status for all contracted staff.
Deficiencies (3)
Failure to properly handle and store potentially hazardous foods, including unlabeled and undated food items and exposure of food to air.
Failure to maintain equipment and kitchen areas to prevent microbial growth and cross contamination, including debris in ice machine and on meat slicer.
Failure to ensure staff vaccination for COVID-19 with inconsistent tracking and securing of accurate vaccination documentation for contracted staff.
Report Facts
Date of inspection: Dec 8, 2022
Number of undated containers: 6
Number of dented cans removed: 5
Number of cutting boards observed with stains: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Food and Beverage | Director of Food and Beverage | Interviewed regarding food storage and labeling deficiencies |
| Executive Chef | Executive Chef | Interviewed regarding food storage and labeling deficiencies |
| Director of Nursing | Director of Nursing | Interviewed regarding COVID-19 vaccination tracking for contracted staff |
| Registered Nurse/Assistant Director of Nursing/Infection Preventionist | RN/ADON/IP | Interviewed regarding COVID-19 vaccination tracking for contracted staff |
| Licensed Nursing Home Administrator | LNHA | Interviewed regarding COVID-19 vaccination tracking for contracted staff |
Inspection Report
Abbreviated Survey
Census: 57
Deficiencies: 1
Date: Feb 25, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations and CDC recommended practices for COVID-19.
Findings
The facility was found to be non-compliant with infection control standards as staff failed to consistently wear appropriate personal protective equipment (PPE), specifically eye protection and gowns, when caring for residents under transmission-based precautions (TBP) for COVID-19. Corrective actions and staff education were implemented to address these deficiencies.
Deficiencies (1)
Failure to don appropriate PPE of eye protection and gown for a resident identified as a person under investigation (PUI) for possible COVID-19 exposure.
Report Facts
Census: 57
Sample size: 5
Completion date for plan of correction: Apr 5, 2021
Post-certification revisit date: Apr 7, 2021
Inspection Report
Routine
Census: 68
Deficiencies: 0
Date: Jan 26, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 30, 2020
Visit Reason
The inspection was conducted due to concerns about the facility's failure to consistently implement and modify care plan safety interventions to prevent falls for a resident identified as high fall risk.
Complaint Details
The visit was complaint-related, focusing on Resident #23's repeated falls and the facility's failure to update care plans and interventions accordingly. The complaint was substantiated by observations, medical record reviews, and staff interviews.
Findings
The facility failed to update the care plan with new interventions after multiple falls of Resident #23, who had cognitive impairment and poor safety awareness. The Director of Nursing acknowledged the lack of documentation for fall interventions after each fall incident.
Deficiencies (1)
Failure to consistently implement and modify Care Plan safety interventions to prevent falls for Resident #23, a high fall risk resident.
Report Facts
Fall incidents: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse Unit Manager | LPN UM | Interviewed regarding Resident #23's falls and the process for completing Incident and Accident Reports. |
| Director of Nursing | DON | Interviewed and acknowledged the lack of documentation for fall interventions on Resident #23's care plan. |
| Certified Nursing Assistant | CNA | Interviewed about Resident #23's cognitive impairment, impulsiveness, and fall risk. |
| Licensed Practical Nurse #1 | LPN #1 | Interviewed about updating care plans after falls and admitted failure to update interventions after Resident #23's fall. |
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